1. Sustainable Health Systems means Democratizing Health
Ilona Kickbusch
Careum Foundation, Zürich, Switzerland
Brussels PiSCE conference
Kickbusch Brussels 2017

2. The Turning point
We are at a turning point in health policy: the nature of 21st century health, changes in society and technology call for a radical change of mindset and a reorganization of how we govern health in the 21st century.
This changes the role of the health sector, of the health professionals, of patients and of citizens – and of other sectors and societal actors including the private sector.
We need intelligent systems for health with a focus on equity and participatory governance.
Kickbusch Brussels 2017

3. Health - what
"Health is a precondition, outcome, and indicator of a sustainable society, and should be adopted as a universal value and shared social goal and political objective for all" (Oslo Lancet Report 2014)
Kickbusch Brussels 2017

4. Health - where
Health is created at the local level in the settings of everyday life, in the neighbourhoods and communities where people of all ages live, love, work, shop and play.
Kickbusch Brussels 2017

5. Sustainability -the goal:
Creating health in the context of everyday life
A system built for active citizens and critical consumers
Supporting the most vulnerable
A patient centered health care system – chronic disease
A system built for active and empowered patients, their families and carers
Supporting the most vulnerable
Kickbusch Brussels 2017

6. Sustainable (health care) systems
Means designing systems with inherent “resilience” by taking advantage of fundamental properties such as diversity, efficiency, adaptability, and cohesion.
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7. Whole systems approach
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8. Sustainability only possible through a patient centered system
The old way of governing health—sectoral, hierarchical, focused on cure, based on a medical paradigm—is no longer sufficient to address the new challenges, and has also reached its limits with regard to the organisation of the health care sector itself.
expansion of self governance for health: health literacy, empowerment, self management and monitoring, self reliance – powered by IT revolution
Kickbusch Brussels 2017

9. Sustainability implies a power shift
Chronic disease + technology + patients will change the face of the health care system: co production
NCDs + citizens action will change the face of health promotion and prevention: co benefits for health
VALUES
System design
SYSTEMS LITERACY
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10. At the centre: Patients – citizens
What we want as individual patients and how we articulate these needs can be distinguished from our collective aspirations as citizens or members of the public (Coulter 2005).
As citizens we may be concerned about abstract notions of what constitutes a ‘good’ service, for example: affordability; efficiency and value for money; universality, equity and fairness; safety and quality; health protection and disease prevention.
As patients, we do not lose our citizen concerns at the door of the GP surgery or the hospital, but we naturally prioritize our own interactions with the system, especially with the health professionals who deliver our care. Individual engagement includes concepts such as personalization and choice,
Collective engagement is concerned with strengthening the public voice, by encouraging democratic accountability and ensuring that the health system is responsive to people’s needs and preferences. (Coulter 2011)
HEALTH CITIZENSHIP – HEALTH LITERACY
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11. Rethink the system: learn from the IT Revolution
The user should not be learning the language of the device – the device must learn the language of the user.
Der Spiegel Nr.41/ S 75
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12. Sustainability means co-production of health
HEALTH CITIZENSHIP
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13. Chronic disease redefines the medical home +the expert
The health system supports the patient and her carers – starts with where people live, love, work and play ----
Health promotion, prevention, integrated care, ambient assisted living, PCMH patient centered medical home are conceived as a system not as silos
The interface with other systems – social care – is a quality standard
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14. Diversity of care
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15. Co production: has synergistic outcomes
Increased satisfication with services
Promotes social participation
Strengthens political engagement
Reduces costs through active participation
Improves quality and outcomes through participation
BUT: Participation requires structures and competence (health literacy)
Social inequality reduces participation as well as health
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16. What must the health care system learn?
Provide opportunities for personal growth and development to people, so that they are treated as assets, not burdens on an overstretched system.
Invest in strategies that develop the emotional intelligence and capacity of local communities.
Use peer support networks instead of just professionals as the best means of transferring knowledge and capabilities. (NEF)
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17. Example: Ontario’s Chronic Disease Prevention and Management Framework
Health Care Organizations that make systematic efforts to improve prevention and management of chronic disease;
Delivery System Design that is focused on prevention and that improves access, continuity of care and flow through the system;
Provider Decision Supports that integrate evidence-based guidelines into daily practice;
Information Systems that enhance information for providers so they can provide quality care, that support individuals in managing their diseases, and that integrate services across the system;
Kickbusch Brussels 2017

18. Example: Ontario’s Chronic Disease Prevention and Management Framework
Personal Skills and Self-Management Supports that empower individuals to build skills for healthy living and coping with disease;
Healthy Public Policies that improve individual and population health and address inequities;
Supportive Environments that remove barriers to healthy living and promote safe, enjoyable living and working conditions;
Community Action that encourages communities to increase control over issues affecting the health of their residents.
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19. Evidence
Kaiser Permanente USA adopted a series of systematic measures to address chronic disease, putting patients in the centers and ensuring integrated care
Over a ten year period it achieved:
A heart disease mortality rate that is 30% lower than in other plans;
A 15% decrease in death rates from congestive heart failure from ;
A smoking rate of 12% among plan members from northern California compared to 18% for the state as a whole (Kaiser Permanente).
Kickbusch Brussels 2017

20. Health CO benefits Active Urban transport:
Active travel, such as cycling and walking, and lower-emission motor vehicles could lead to substantial reductions in greenhouse gas emissions and the burden of chronic diseases.
In London, the strategies could reduce the disease burden from heart disease and stroke by 10-20%, breast cancer by 12-13%, dementia by 8% and depression by 5%.
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21. Sustainability – planetary health
The health of people can no longer be seen separate from the health of the planet and wealth measured along with parameters of growth will no longer ensure health.
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22. Final thoughts
Governance for health is not only about “governing better for results” in terms of outcome but also in normative terms of values and process. A health system is also a social system.
This implies the foundation in a human rights based approach including a commitment to health equity and the democratization of health.
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23. Sustainable development goals
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